OSJCT Coombe End Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider had a values statement and policies and procedures, setting out expectations on how staff should work. Staff were aware of these documents and where they could find them. Information was communicated to staff through their intranet and in regular staff meetings.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The service had experienced a period of management change, with the long-term absence of the registered manager. The provider had appointed a peripatetic operations manager to lead the service in the absence of the registered manager. The area operations manager had also provided additional support to the service and senior staff had been seconded from other services to assist with the leadership of the service. Staff told us they felt supported by the management approach.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents were recorded and reviewed by managers to ensure action to reduce the risk of a repeated incident were taken. Learning from incidents was shared with all staff to ensure they understood any changes to the way they needed to support people. Information from incidents was included in staff handover records, to ensure staff had key information at the start of their shift. Managers could access these systems remotely, meaning senior managers could maintain oversight of what was happening in the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had processes in place for staff to request flexibility in their work patterns, for example to enable staff with caring responsibilities or those with health conditions to remain working. Staff were aware of these processes and told us they felt supported by the management team.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. There was a range of monitoring and auditing systems used by the provider, including feedback from people and their relatives, feedback from staff and observations of staff practice. This information was used to create a service improvement plan, which had clear actions and a timescale for completion. The plan was regularly reviewed by the manager and area operations manager to ensure actions had been completed. The provider had identified shortfalls in the support for people to manage their medicines and taken effective action to strengthen oversight and make improvements. These were ongoing at the time of the inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. People and relatives gave examples of the service working in partnership with other agencies, including health and social care services. Professional partners gave positive feedback about their experience of working with the service to meet people’s needs. A local authority commissioner told us, “The divisional director has been proactive in keeping me updated weekly on progress made at Coombe End Court and I have found [leaders] to be transparent in their approach to working with me as their allocated commissioner”.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Systems for monitoring standards of care were used to identify areas of improvement and lessons learned. This included regular audits and quality assurance checks. The provider had systems in place to share learning from incidents in other services. However, we observed learning from other services had not always been implemented. For example, learning relating to the storage of denture cleaning tablets had not been implemented in the service’s own shop and learning regarding the position of wheelchair footplates was not consistently followed. The manager took immediate action to address these issues during the inspection.